Late presentation of 'Lemierre's syndrome': how a delay in seeking healthcare and reduced access to routine services resulted in widely disseminated Fusobacterium necrophorum infection during the global COVID-19 pandemic.

The SARS-CoV-2 outbreak has disrupted the delivery of routine healthcare services on a global scale. With many regions suspending the provision of non-essential healthcare services, there is a risk that patients with common treatable illnesses do not receive prompt treatment, leading to more serious and complex presentations at a later date. Lemierre's syndrome is a potentially life-threatening and under-recognised sequela of an oropharyngeal or dental infection. It is characterised by septic embolisation of the gram-negative bacillus Fusobacterium necrophorum to a variety of different organs, most commonly to the lungs. Thrombophlebitis of the internal jugular vein is frequently identified. We describe an atypical case of Lemierre's syndrome involving the brain, liver and lungs following a dental infection in a young male who delayed seeking dental or medical attention due to a lack of routine services and concerns about the SARS-CoV-2 outbreak.

Prospects on Nano-Based Platforms for Antimicrobial Photodynamic Therapy Against Oral Biofilms.

Objective: This review clusters the growing field of nano-based platforms for antimicrobial photodynamic therapy (aPDT) targeting pathogenic oral biofilms and increase interactions between dental researchers and investigators in many related fields. Background data: Clinically relevant disinfection of dental tissues is difficult to achieve with aPDT alone. It has been found that limited penetrability into soft and hard dental tissues, diffusion of the photosensitizers, and the small light absorption coefficient are contributing factors. As a result, the effectiveness of aPDT is reduced in vivo applications. To overcome limitations, nanotechnology has been implied to enhance the penetration and delivery of photosensitizers to target microorganisms and increase the bactericidal effect. Materials and methods: The current literature was screened for the various platforms composed of photosensitizers functionalized with nanoparticles and their enhanced performance against oral pathogenic biofilms. Results: The evidence-based findings from the up-to-date literature were promising to control the onset and the progression of dental biofilm-triggered diseases such as dental caries, endodontic infections, and periodontal diseases. The antimicrobial effects of aPDT with nano-based platforms on oral bacterial disinfection will help to advance the design of combination strategies that increase the rate of complete and durable clinical response in oral infections. Conclusions: There is enthusiasm about the potential of nano-based platforms to treat currently out of the reach pathogenic oral biofilms. Much of the potential exists because these nano-based platforms use unique mechanisms of action that allow us to overcome the challenging of intra-oral and hard-tissue disinfection.

Antibiotic prescription patterns for treating dental infections in children among general and pediatric dentists in teaching institutions of Karachi, Pakistan.

BACKGROUND: Antibiotics are regularly prescribed by dental professionals in their practice, for the purpose of dental treatment as well as for the prevention of infection. The inappropriate use of antibiotics is a significant factor in the rise of antibiotic resistance. There is an immediate need for the advancement of prescribing guidelines and instructive polices to encourage the rational and appropriate utilization of medications especially antibiotics in dentistry. OBJECTIVE: The aim of this study was to identify the frequency of antibiotic prescription for treating dental infections in children among dentists in teaching institutions of Karachi, Pakistan and whether they are adhering to the prescribed international guidelines. METHODS: A cross-sectional study was conducted in three private and two public colleges of Karachi. After taking written informed consent and checking the inclusion criteria, a total of 380 participants were interviewed using a pre-designed validated questionnaire which included demographic profile and clinical case scenarios. Data were entered and analyzed on SPSS version 20. Inferential analysis was performed using chi-square test. The significance level was set at 0.05. RESULTS: Of the 380 subjects, a majority (71.3%) treated 15 or less children per month (n = 271) while 28.7% of dentists (n = 109) treated more than 15 children per month. Overall adherence to American Academy of Pediatric Dentistry guidelines was low from 26.1% to 44.2%. The difference between adherence of dentists with low and high volume of pediatric patients was significantly different for case scenarios 1, 3, 4 and 5 (p<0.001 for all) where dentists who treated 15 or less children per month were more likely to be adherent to standard antibiotic prescription guidelines than those who treated more than 15 children per month. CONCLUSIONS: This study shows that majority of dentists, particularly dentists with high volume of pediatric patients lacked adherence to professional guidelines for prescribing antibiotics for treating dental infection in children. There seem to be a lack of harmony between the recommended professional guidelines and the antibiotic prescribing pattern of dentists. Regular updates and continuing medical education for the health professionals regarding comprehensible and specific professional guidelines may lead to improved adherence of antibiotics prescription amongst dentists.

[Therapeutic prescription of antibiotics and NSAID's by dentists in the Netherlands]. / Therapeutisch voorschrijven van antibiotica en NSAID's door tandartsen in Nederland.

Late in 2015 the Royal Dutch Dental Association (KNMT) conducted a study of the therapeutic prescription of antibiotics and NSAIDs by dentists in general practice in the Netherlands and the factors influencing their decisions. Of the 1,087 dentists contacted 367 (34%) completed the online questionnaire. In the 4 weeks preceding the study they had prescribed an antibiotic to 1.3% of their patients on average. A fifth (20%) found it difficult to decide whether an anti-inflammatory drug is indicated and/or whether this should be an antibiotic or a NSAID. Questioned about medication decisions (whether or not antibiotics are indicated) in 11 fictional cases, 11% of respondents judged every case correctly. 39% undertreated, 24% overtreated and 26% both undertreated and overtreated. In the last two categories, dentists with non-Dutch degrees are overrepresented. More than half (55%) of the respondents say they need a guideline for prescribing antibiotics in dental treatment and 28% (also) need postgraduate education on this matter.

The panoramic dental radiograph for emergency physicians.

Dental emergencies are common reasons for presenting to hospital emergency departments. Here, we discuss the panoramic radiograph (orthopantomogram (OPG, OPT) as a diagnostic tool for the assessment of mandibular trauma and odontogenic infections. In this article, we review the radiographic principles of image acquisition, and how to conduct a systematic interpretation of represented maxillofacial anatomy. The aim is to equip the emergency physician with the skills to use the OPG radiograph when available, and to rapidly assess the image to expedite patient management. Included is a discussion of a number of cases seen in the emergency setting and some common errors in diagnosis.

Severe odontogenic infections: a 5-year review of a major referral hospital in Ghana.

INTRODUCTION: Odontogenic infections are fairly common in healthcare settings. However, late presentations such as Ludwig's angina, facial cellulitis, necrotizing cervical fasciitis (NCF), among others could lead to mortality. In view of suggestions that the occurrence of severe, near-fatal odontogenic infections is declining, this study set out to determine the incidence of such severe odontogenic infections over the past 5 years at the Korle-Bu Teaching Hospital, a major referral centre in Ghana. METHODS: A retrospective review was done, involving all patients with severe odontogenic infection, thereby requiring admission, per stated criteria at the Department of Oral and Maxillofacial Surgery (Dental clinic), Korle-Bu Teaching Hospital, in the period between July 2012 and July 2017. The cumulative incidence for the respective years were then computed for the years of review. RESULTS: A total of 243 patients were included in the study. This consisted of 121 males and 122 females, with an average age of 42.9 years (SD = 16.6), ranging from 18 months to 91 years. Incidence proportions for the years of the review were 8.2, 8.9, 17.7, 17.9 and 27.7 people per 1000 cases of tooth-related infections for the respective years. With a fatality rate of 5.8%, the incidence of odontogenic infections among patients attending the outpatient Dental clinic of the hospital is 40.3%, while that of dentoalveolar abscess is 6.2%. Ludwig's angina was the commonest (52%) form of presentation of spreading odontogenic infection. CONCLUSION: This study highlights the importance of persisting severe, near-fatal odontogenic infections in Ghana. Not only is there a need to assess the public, professional and institutional strategies to management, but for more evidence-based studies in our local setting to aid in management.

Antibacterial bone substitute of hydroxyapatite and magnesium oxide to prevent dental and orthopaedic infections.

Bone substitutes market is growing due to the great demand for bone regenerative therapies. However, most of the actual products available in the market are incapable of inhibiting bacterial colonization, which can lead to tissue infection and possible implant failure. Some bone substitutes are combined with antibiotics to avoid the development of implant-associated infections, but the growing bacterial resistance to antibiotics often makes these products ineffective. Therefore, it is mandatory to develop new and alternative approaches. In the present work, a granular bone substitute of hydroxyapatite was produced, where different percentages of magnesium oxide were introduced. The antibacterial activity and biofilm formation was evaluated towards Staphylococcus aureus and Escherichia coli. The inclusion of magnesium oxide particles reduced bacterial growth and biofilm formation in a concentration-dependent manner, when compared with pure hydroxyapatite materials. Superior antibacterial activity and inhibition of biofilm formation was observed for Staphylococcus aureus with complete eradication when magnesium oxide percentages were equal or above 3 wt%. The materials cytotoxicity was assessed under ISO 10993-5:2009 guidance and through Live/Dead cell marking and none of the produced granules was cytotoxic. In addition, reactive oxygen species production was also evaluated and the results revealed that the exposure to the materials extracts did not induce the formation of reactive oxygen species by cells.

Lipoteichoic acids of lactobacilli inhibit Enterococcus faecalis biofilm formation and disrupt the preformed biofilm.

Enterococcus faecalis, a Gram-positive bacterium commonly isolated in patients with refractory apical periodontitis, invades dentin tubules easily and forms biofilms. Bacteria in biofilms, which contribute to recurrent and/or chronic inflammatory diseases, are more resistant to antimicrobial agents than planktonic cells and easily avoid phagocytosis. Although Lactobacillus plantarum lipoteichoic acid (Lp.LTA) is associated with biofilm formation, the effect of Lp.LTA on biofilm formation by E. faecalis is not clearly understood. In this study, we investigated whether Lp.LTA inhibits E. faecalis biofilm formation. The degree of biofilm formation was determined by using crystal violet assay and LIVE/DEAD bacteria staining. The quantification of bacterial growth was determined by measuring the optical density at 600 nm with a spectrophotometer. Formation of biofilms on human dentin slices was observed under a scanning electron microscope. E. faecalis biofilm formation was reduced by Lp.LTA treatment in a dose-dependent manner. Lp.LTA inhibited biofilm development of E. faecalis at the early stage without affecting bacterial growth. LTA from other Lactobacillus species such as Lactobacillus acidophilus, Lactobacillus casei, or Lactobacillus rhamnosus GG also inhibited E. faecalis biofilm formation. In particular, among LTAs from various lactobacilli, Lp.LTA showed the highest inhibitory effect on biofilms formed by E. faecalis. Interestingly, LTAs from lactobacilli could remove the biofilm preformed by E. faecalis. These inhibitory effects were also observed on the surface of human dentin slices. In conclusion, Lactobacillus species LTA inhibits biofilm formation caused by E. faecalis and it could be used as an anti-biofilm agent for prevention or treatment against E. faecalis-associated diseases.

Detection of the antimicrobial resistance genes blaTEM-1, cfxA, tetQ, tetM, tetW and ermC in endodontic infections of a Mexican population.

OBJECTIVES: The aim of this study was to identify the prevalence of genes encoding resistance to three groups of antimicrobial agents in root canal samples from primary infection or post-treatment disease in Mexico. METHODS: A total of 64 subjects requiring root canal treatment because of primary infection or post-treatment disease were enrolled in this cross-sectional analytical study. Root canal samples were obtained and DNA was isolated. Specific primers for six antimicrobial resistance genes (ARGs) and seven bacterial taxa (five genera and two species) were used. Student's t-test, χ2 test and Fisher's exact test were applied where appropriate to detect statistical differences. RESULTS: The blaTEM-1, ermC and tetM genes were found more frequently in the post-treatment disease group compared with the primary infection group. The occurrence of assessed bacteria was similar in both groups, except for Enterococcus spp. and Porphyromonas endodontalis, which were found at a significantly higher frequency in the post-treatment disease group. It was observed that the post-treatment disease group harboured more ARGs. The most frequent ARG was tetW, whereas tetQ and cfxA were not detected in any case. With respect to bacterial taxa, Fusobacterium spp. was present in 100% of samples, whereas Porphyromonas gingivalis was not observed in any of the samples. CONCLUSIONS: At least one ARG was detected in all cases; moreover, 32.8% of samples were positive for four ARGs, 54.7% for three ARGs, 9.4% for two ARGs and only 3.1% for one ARG. This indicates a high prevalence and diversity of ARGs in these root canal samples.

Determination and identification of antibiotic-resistant oral streptococci isolated from active dental infections in adults.

OBJECTIVE: To determine and identify antibiotic-resistant bacteria (ARB) of oral streptococci from active dental infections in adults and its association with age and gender. MATERIAL AND METHODS: This cross-sectional study included 59 subjects from 18 to 62 years old. Ninety-eighth samples obtained from the subjects were cultivated in agar plates containing antibiotics amoxicillin/clavulanic acid (A-CA), clindamycin, and moxifloxacin (concentrations of 16, 32 or 64 µg/ml). PCR assay was performed to identify bacterial species. RESULTS: The bacterial species that showed more antibiotic-resistance (AR) was S. mutans (45.9%), followed by S. gordonii (21.6%), S. oralis (17.6%), S. sanguinis (9.5%), S. salivarius (5.4%) and S. sobrinus (0%). Moreover, clindamycin (59.4%) showed the highest frequency of AR. Moxifloxacin and A-CA showed an susceptibility >99.1%, while clindamycin showed the lowest efficacy (93.3%); there was a significant statistically difference (p < .01). The age group between 26 and 50 years old (32.2%) and females (28.8%) showed more multiresistance. Clindamycin showed a statistical difference (p < .05) when comparing groups by gender. CONCLUSIONS: Clindamycin was the antibiotic with the highest frequency of ARB and lower bactericidal effect. Moxifloxacin and A-CA showed the highest efficacy and the lowest ARB frequency. Streptococcus mutans was the bacterial specie that showed an increased frequency of AR.

A systematic review of dental disease management in cancer patients.

INTRODUCTION: This systematic review aims to update on the prevalence of odontogenic-related infections and the efficacy of dental strategies in preventing dental-related complications in cancer patients since the 2010 systematic review. REVIEW METHOD: A literature search was conducted in the databases MEDLINE/PubMed and EMBASE for articles published between 1 January 2009 and 30 June 2016. Each study was assessed by 2 reviewers and the body of evidence for each intervention was assigned an evidence level. RESULTS: After examination of the abstracts and full-text articles, 59 articles satisfied the inclusion criteria. The weighted prevalence of dental infections and pericoronitis during cancer therapy was 5.4 and 5.3%, respectively. The frequency of dental-related infections during intensive chemotherapy after complete, partial, and minimal pre-cancer dental evaluation/treatment protocols ranged from 0 to 4%. Protocols involving third molars extractions had the highest complications (40%). CONCLUSIONS: In view of the low prevalence of infections and the potential for complications after third molar extractions, it is suggested that partial dental evaluation/treatment protocols prior to intensive chemotherapy; whereby minor caries (within dentin), asymptomatic third molars or asymptomatic teeth without excessive probing depth (<8 mm), mobility (mobility I or II) or with periapical lesions of <5 mm were observed; is a viable option when there is insufficient time for complete dental evaluation/treatment protocols. The use of chlorhexidine, fluoride mouth rinses as well as composite resin, resin-modified glass ionomer cement (GIC), and amalgam restorations over conventional GIC in post head and neck radiation patients who are compliant fluoride users is recommended.

Variant of Lemierre's syndrome with internal jugular vein aneurysm.

Internal jugular vein (IJV) aneurysm is a rare entity, and a thrombosed aneurysm poses diagnostic and management challenges. We came across a 53-year-old woman who presented with fever, vomiting and right neck swelling for a week. Laboratory investigations showed neutrophilic leucocytosis, raised acute phase reactant and blood culture yielded Klebsiella pneumoniae Ultrasound and contrast-enhanced CT neck revealed a large fusiform aneurysm of the right IJV with filling defect extending from the aneurysm into the right transverse sinus. There was a cavity at the right lower third molar tooth. MRI confirmed the findings with additional enhancing focus at right lower periodontal region. The swelling reduced after 2 weeks of medical therapy, and follow-up imaging 4 months later showed complete resolution of the aneurysm with residual thrombosis. After extensive workup, dental infection remains the only identifiable primary source leading to thrombophlebitis of the right IJV and subsequent sequelae.

Manejo de las infecciones odontogénicas en las consultas de atención primaria: ¿antibiótico? / Management of odontogenic infections in Primary Care: Antibiotic?

Nuestro objetivo es intentar contribuir al uso racional de los antibióticos prescritos por los médicos de familia cuando un paciente consulta por un problema odontológico. Actualmente la pregunta que nos debemos hacer es si hay que tomar antibiótico, en lugar de cuál dar. Revisamos las principales infecciones odontológicas, cuál debe ser el tratamiento adecuado y el papel de la prevención. Es necesario conocer la complejidad de la microflora de la cavidad oral, pues de ella dependerá la conveniencia de antibioterapia, la evolución hacia la curación o la progresión de algunas infecciones odontogénicas. La placa bacteriana, formada por el biofilm, se comporta como una barrera para la acción de los antimicrobianos. Es en la prevención de su formación, así como en la eliminación mecánica de esta una vez formada, en lo que el médico de familia debe insistir. Debemos transmitir a la población que los antibióticos no curan el dolor dental

Our aim is to contribute to the rational use of antibiotics prescribed by family doctors when a patient consults for a dental problem. Nowadays we should not ask which antibiotic to give. The question has to be if we need to prescribe antibiotics in front of the most common odontogenic infections seen in our practice. We review the main dental infections, which should be their appropriate management and the role of prevention. We need to know the complexity of the oral microbiome because it’l depend on the appropriateness of the antibiotherapy, the evolution towards cure or progression of some odontogenic infections. The bacterial plaque, formed by the biofilm, behaves as a barrier to the action of antimicrobials. It’s in the prevention of its development as well as in it mechanical elimination once shaped, in what the family doctor should insist. We must transmit antibiotics don’t heal dental pain

C-reactive protein concentration as a prognostic factor for inflammation in the management of odontogenic infections.

Our aim was to find out if it is possible to correlate the duration of stay in hospital, the severity of infection, involvement of particular anatomical spaces, white cell count, efficacy of surgical treatment, and fever with C-reactive protein (CRP) concentrations on admission. One hundred patients met our inclusion criteria. After their notes had been examined they were subdivided according to whether the infection of the main facial space involved was less severe, moderately severe, or very severe. The relations between degree of severity and CRP concentration on admission (<100mg/L compared with 100+), age (years), sex, and duration of hospital stay (days) were examined using Poisson regression (because the distribution of characteristics, and particularly the duration of stay, were skewed). The overall model was significant (p=0.003). Pearson and deviance chi square tests did not indicate overdispersion (p=0.97 in both cases), which suggested that the assumptions about the Poisson distribution were valid. Log-rank chi square tests indicated that only severity had a significant effect (p=0.0001), and C-reactive protein concentration was not significantly associated with group on admission, age, or sex. The moderately and very severe groups had longer median (range) durations of stay than the less severe group (5 (2-8) compared with 3 (1-8) days, respectively). CRP concentration was not a prognostic factor for the extent of odontogenic infections or presumed duration of stay, but severity scoring was a significant factor in the prediction of duration of stay in hospital.

Oral health conditions in leprosy cases in hyperendemic area of the Brazilian Amazon.

Leprosy is a hyperendemic chronic condition in the Rondônia State . Despite the significant impact of oral health on the quality of life and clinical evolution of leprosy patients, systematic evaluation of oral health status has been neglected. To analyze the dental-clinical profile, self-perceived oral health and dental health service access of leprosy cases in the municipality of Cacoal in Rondônia State , North Brazil, from 2001 to 2012. A descriptive, cross-sectional study design was performed based on dental evaluation and standardized structured instruments. We investigated clinically assessed and self-perceived oral health status, as well as dental health service access. A total of 303 leprosy cases were included; 41.6% rated their oral health as good, and 42.6% reported being satisfied with their oral health. Self-reported loss of upper teeth was 45.5%. The clinical evaluation revealed that 54.5% had active caries. Most (97.7%) cases reported having been to the dentist at least once in their life and 23.1% used public health services. The poor standard of oral health in this population may increase the risk for leprosy reactions, consequently reducing quality of life. Low access to public health dental services and poor self-perceived oral health reinforce the need to achieve comprehensive health care in this population.

Carriage frequency, phenotypic, and genotypic characteristics of methicillin-resistant Staphylococcus aureus isolated from dental health-care personnel, patients, and environment.

There is limited data on methicillin-resistant Staphylococcus aureus (MRSA) carriage in dental clinics. 1300 specimens from patients, health personnel, and environmental surfaces of a dental clinic in Egypt were tested for MRSA. Antibiotic susceptibility, biofilm formation, Staphylococcal protein A (spa) typing, SCCmec typing, and PCR-based assays were used to detect mecA, mecC, vanA, Panton-Valentine Leukocidin toxin (PVL), and toxic shock syndrome toxin-1 (tst) genes. Among 34 mecA-positive MRSA isolates, five (14.7%) were PVL-positive, seventeen (50%) were tst-positive, ten (29.4%) were vanA-positive, while none harboured mecC. MRSA hand carriage rates in patients, nurses, and dentists were 9.8%, 6.6%, and 5%. The respective nasal colonization rates were 11.1%, 6.7%, and 9.7%. 1.3% of the environmental isolates were MRSA-positive. Strong and moderate biofilm-forming isolates represented 23.5% and 29.4% of MRSA isolates. 24 MRSA isolates (70.6%) were multi-resistant and 18 (52.9%) harboured SCCmec IV. Among eight spa types, t223 (26.5%), t267 (23.5%), and t14339 (23.5%) were predominant. We noted an alarming genetic relatedness between 7 (20.6%) MRSA isolates and the epidemic EMRSA-15 clone, as well as a combined occurrence of tst and PVL in 3 (8.8%) isolates. Results suggest high MRSA pathogenicity in dental wards highlighting the need for more efficient surveillance/infection control strategies.